Health Insurance Prospectus - Platinum 1

Transcription

1 SALIENT FEATURES OF THE POLICY UNITED INDIA INSURANCE COMPANY LIMITED REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI HEALTH INSURANCE PROSPECTUS - PLATINUM 1.1 Entry age to the policy is 18 years to 35 years. Children from age of three months can be covered if one or both parents are covered Sum insured: Rs 1 lac to Rs 10 lacs in multiples of Rs 25,000/- 2 The policy covers A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses. B. Intensive Care Unit(ICU) expenses not exceeding 2% of the sum insured per day or actual amount whichever is less. C. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees D. Anaesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, Cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X Ray and other medical expenses related to the treatment. E. Hospitalisation expenses (excluding cost of organ) incurred on donor in respect of organ transplant to the insured. Note: 1.The amount payable under 2.1C & D above shall be at the rate applicable to the entitled room category. In case the Insured person opts for a room with rent higher than the entitled category as in 2.1A above, the charges payable under 2.1C & D above shall be limited to the charges applicable to the entitled category. This will not be applicable in respect of medicines & drugs and implants. Note: 2. No payment shall be made under 2.1C above other than as part of the hospitalisation bill. 2.2 Domiciliary Hospitalisation as defined in Clause 3.7 below for a period exceeding three days and Subject however that domiciliary hospitalisation benefits shall not cover: i)expenses incurred for pre and post hospital treatment and ii)expenses incurred for treatment for any of the following diseases:- a) Asthma b) Bronchitis c) Chronic Nephritis and Nephritic Syndrome d) Diarrhoea and all type of Dysenteries including Gastroenteritis e) Diabetes Mellitus and Insipidus f) Epilepsy g) Hypertension h) Influenza, Cough and Cold i) All Psychiatric or Psychosomatic Disorders 10) Pyrexia of unknown Origin for less than 10 days 11) Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharangitis 12) Arthritis, Gout and Rheumatism Health Insurance Prospectus - Platinum 1

2 Liability of the company under this clause is restricted as stated in the Schedule attached hereto 2.3 Expenses on Hospitalisation upon written advice of a Medical Practitioner, for minimum period of 24 consecutive hours are admissible. However, this time limit is not applied to specific treatments, such as, 1 Adenoidectomy 19 FESS 2 Appendectomy 20 Haemo dialysis 3 Ascitic/Pleural tapping 21 Fissurectomy / Fistulectomy 4 Auroplasty 22 Mastoidectomy 5 Coronary angiography 23 Hydrocele 6 Coronary angioplasty 24 Hysterectomy 7 Dental surgery 25 Inguinal/ventral/ umbilical/femoral hernia 8 D&C 26 Parenteral chemotherapy 9 Endoscopies 27 Polypectomy 10 Excision of Cyst/granuloma/lump 28 Septoplasty 11 Eye surgery 29 Piles/ fistula 12 Fracture/dislocation excluding hairline 30 Prostrate fracture 13 Radiotherapy 31 Sinusitis 14 Lithotripsy 32 Tonsillectomy 15 Incision and drainage of abcess 33 Liver aspiration 16 Colonoscopy 34 Sclerotherapy 17 Varicocelectomy 35 Varicose Vein Ligation 18 Wound suturing This condition will also not apply in case of stay in hospital of less than 24 hours provided - a. The treatment is undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement and b. Which would have otherwise required a hospitalisation of more than 24 hours. Note: Procedures/treatments usually done in out-patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centres. 2.4 For Ayurvedic Treatment, hospitalisation expenses are admissible only when the treatment has been undergone in a Government Hospital or in any Institute recognised by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health. (N.B: Company's Liability in respect of all claims admitted during the period of insurance shall not exceed the Sum Insured per person as mentioned in the schedule) MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS If the claim event falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two policy periods, including the deductibles for each policy period. Such eligible claim amount to be payable to the insured shall be reduced to the extent of premium to be received for the renewal/due date of premium of health insurance policy, if not received earlier. 3. DEFINITIONS: 3.1 A Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under Health Insurance Prospectus - Platinum 2

3 a. Has qualified nursing staff under its employment round the clock. b. Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places; c. Has qualified medical practitioner(s) in charge round the clock; d. Has a fully equipped Operation Theatre of its own where surgical procedures are carried out; e. Maintains daily records of patients and makes these accessible to the insurance company s authorized personnel. 3.2 Hospitalisation Means admission in a Hospital/Nursing Home for a minimum period of 24 Inpatient care consecutive hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours. 3.3 ANY ONE ILLNESS Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital / Nursing Home where treatment has been taken. 3.4 CASHLESS FACILITY Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent preauthorisation approved. 3.5 DAY CARE CENTRE Day Care centre means any institution established for day care treatment of illness and/or injuries or a medical set-up within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under : a. Has qualified nursing staff under its employment b. Has qualified Medical Practitioner(s) in charge c. Has a fully equipped operation theatre of its own where surgical procedures are carried outd. Maintains daily records of patients and will make these accessible to the Insurance Company s authorized personnel. 3.6 DAY CARE TREATMENT - Day Care treatment means the medical treatment and/or surgical procedure which is (i). Undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological and (ii) which would have otherwise required a hospitalisation of more than 24 hours. Treatment normally taken on an out-patient basis is not included in the scope of this definition. 3.7 DOMICILIARY HOSPITALISATION Domiciliary Hospitalisation means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances : A The condition of the patient is such that he/she is not in a condition to be removed to a hospital or B The patient takes treatment at home on account of non-availability of room in a hospital. 3.8 GRACE PERIOD Grace Period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received. 3.9 ID CARD ID card means the identity card issued to the insured person by the TPA to avail cashless facility in network hospitals. Health Insurance Prospectus - Platinum 3

4 3.10 MEDICALLY NECESARY Medically Necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which - Is required for the medical management of the illness or injury suffered by the insured; - Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity; - Must have been prescribed by a Medical Practitioner; Must conform to the professional standards widely accepted in international medical practice or by the medical community in India MEDICAL PRACTITIONER A Medical Practitioner is a person who holds a valid registration from the Medical Council of any State of India or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of licence. The term Medical Practitioner would include Physician, Specialist and Surgeon. (The Registered Practitioner should not be the insured or close family members such as parents, in-laws, spouse and children) NETWORK PROVIDER Network Provider means the hospital/nursing home or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility. The list of Network Hospitals is maintained by and available with the TPA and the same is subject to amendment from time to time. Preferred Provider Network means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The list is available with the company/tpa and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing PORTABILITY Portability means transfer by an Individual Health Insurance Policyholder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another PRE-EXISTING DISEASE Any condition, ailment or injury or relation condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment within 48 months to prior to the first policy issued by the insurer PRE HOSPITALISATION MEDICAL EXPENSES Relevant medical expenses incurred immediately 30 days before the Insured person is hospitalised provided that ; a. Such Medical expenses are incurred for the same condition for which the Insured Person s Hospitalisation was required; and b. The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance Company 3.15 POST HOSPITALISATION MEDICAL EXPENSES Relevant medical expenses incurred immediately 60 days after the Insured person is discharged from the hospital provided that ; c. Such Medical expenses are incurred for the same condition for which the Insured Person s Hospitalisation was required; and d. The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance Company QUALIFIED NURSE Health Insurance Prospectus - Platinum 4

5 QUALIFIED NURSE means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any State in India REASONABLE AND CUSTOMARY CHARGES Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved THIRD PARTY ADMINISTRATOR TPA means a Third Party Administrator who holds a valid License from Insurance Regulatory and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the Company for the provision of health services as specified in the agreement between the Company and TPA. 4. EXCLUSIONS:- The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of: 4.1 CONGENITAL DISEASES ( EXTERNAL AND INTERNAL) 4.2 Injury / disease directly or indirectly caused by or arising from or attributable to War, invasion, Act of Foreign enemy, War like operations (whether war be declared or not), 4.3 a. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident b. Vaccination and inoculation of any kind unless it is post animal bite c. Change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight, etc d. Plastic surgery other than as may be necessitated due to an accident or as a part of any illness Cost of spectacles and contact lenses, hearing aids. 4.5 Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation. 4.6 Convalescence, general debility; run-down condition or rest cure, obesity treatment and its complications including morbid obesity, Congenital external disease/ defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, Venereal disease, intentional self injury and use of intoxication drugs / alcohol. 4.7 All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS. 4.8 Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home 4.9 Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician 4.10 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon / materials 4.11 Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these including caesarean section, except abdominal operation for extra Health Insurance Prospectus - Platinum 5

6 uterine pregnancy (Ectopic Pregnancy), which is proved by submission of Ultra Sonographic Report and Certification by Gynaecologist that it is life threatening one if left untreated Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatments/ therapies, 4.13 External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or treatment including CPAP, CPAD, Infusion pump etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, elastocrepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any medical equipment, which is subsequently used at home etc Genetic disorders and stem cell implantation/ surgery 4.15 Change of treatment from one system of medicine to another unless recommended by the consultant/ hospital under whom the treatment is taken 4.16 Treatment for Age Related Macular Degeneration (ARMD), treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc All non medical expenses including convenience items for personal comfort such as charges for telephone, television, ayah, private nursing/ barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses. For detailed list of non-payable expenses, please lot on to our website Any kind of Service charges, Surcharges, Admission Fees/Registration Charges, Luxury Tax and similar charges levied by the hospital 5 FAMILY DISCOUNT A family discount of 5% of the total premium will be allowed comprising the insured and any one or more of the following: a. Spouse, b. Dependent children (i.e. Legitimate or legally adopted children) c. Dependent Parents. 6 NOTICE OF CLAIM: Upon the happening of any event which may give rise to a claim under this Policy notice with full particulars shall be sent to the TPA named in the schedule immediately and in case of emergency Hospitalisation within 24 hours from the time of Hospitalisation / Domiciliary Hospitalisation. All supporting documents relating to the claim must be filed with TPA within 15 days from the date of discharge from the hospital. In case of post-hospitalisation, treatment (limited to 60 days), all claim documents should be submitted within 7 days after completion of such treatment. Note: Waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit. 7 PAYMENT OF CLAIM All claims under this policy shall be payable in Indian currency. All medical treatments for the purpose of this insurance will have to be taken in India only. Payment of claim shall be made through TPA to the Hospital/Nursing Home or the Insured Person as the case may be. 8 COST OF HEALTH CHECK UP Health Insurance Prospectus - Platinum 6

7 The insured shall be entitled for reimbursement of the cost of a Health check up authorised TPAs once at the end of block of every three underwriting years provided there are no claims reported during the block and subject to the policy being renewed without break. The amount of such reimbursement shall be limited to 1% of the average SI for the preceding three policy periods. 9 Free Look Period The policy have a free look period which shall be applicable at the inception of the policy and; i. The insured will be allowed a period of at least 15 days from the date of receipt of the policy to review the terms and conditions of the policy and to return the same if nor acceptable. ii. If the insured has not made any claim during the free look period, the insured shall be entitled to a. A refund of the premium paid less any expenses incurred by the insurer on medical examination of the insured persons and the stamp duty charges or b. Where the risk has already commenced and the opinion of return of the policy is exercised by the policyholder, a deduction towards the proportionate risk premium for period on cover or; c. Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period 10 Premium Payment: Premium shall currently be payable as per table attached being the prevailing rates of the company. The Premium for renewal shall ordinarily be payable at the said rates unless the Company deems it necessary to revise the rates of premium for such Policies, in which event subject to prior approval being obtained from the IRDA. 11 Renewal Clause: 1. The Company shall renew this Policy if the Insured shall remit the requisite Premium to the Company prior to expiry of the Period of Insurance stated in the Schedule. 2. The Company shall be entitled to decline renewal if; a) any fraud, misrepresentation or suppression by the Insured or on his behalf is found either in obtaining insurance or subsequently in relation thereto or, b) the Company has discontinued issue of the Policy, in which event the Insured shall however have the option for renewal under any similar Policy being issued by the Company; provided however, benefits payable shall be subject to the terms contained in such other Policy. 3. If the Insured fails to remit Premium for renewal before expiry of the Period of Insurance, but within 30 days thereafter, admissibility of any claim during the period of subsequent Policy shall be considered in the same manner as under a Policy renewed without break. The Company however shall not be liable for any claim arising out of ailment suffered or hospitalisation commencing in the interim period after expiry of the earlier Policy and prior to date of commencement of subsequent Policy. 4. Enhancement of Sum Insured : The Insured may seek enhancement of Sum Insured in writing at or before payment of premium for renewal, which may be granted at the discretion of the Company. However, notwithstanding enhancement, for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding Policy period, liability of the Company shall be only to the extent of the Sum Insured under the Policy in force at the time when it was contracted or suffered Any such request for enhancement must be accompanied by a declaration that the insured or any other insured person in respect of whom such enhancement is sought is not aware of any symptoms or other indications that may give rise to a claim under the policy. The Company may require such insured person/s to undergo a Medical examination to enable the company to take a decision on accepting the request for enhancement in the Sum Insured. 50% of the cost of the Medical examination will be reimbursed to the insured person on acceptance of the request for enhancement of sum insured. Health Insurance Prospectus - Platinum 7

8 12 Cancellation Clause: The Company may at any time cancel the Policy on grounds of misrepresentation, fraud, nondisclosure of material fact or non-cooperation by the insured by sending fifteen days notice in writing by Registered A/D to the insured at his last known address in which case the Company shall return to the insured a proportion of the last premium corresponding to the unexpired period of insurance if no claim has been paid under the policy. The insured may at any time cancel this policy and in such event the Company shall allow refund of premium at Company s short period rate table given below provided no claim has occurred upto the date of cancellation. PERIOD ON RISK Upto one month Upto three months Upto six months Exceeding six months RATE OF PREMIUM TO BE CHARGED. 1/4 th of the annual rate 1/2 of the annual rate 3/4 th of the annual rate Full annual rate. 13 PORTABILITY In the event of insured porting to another insurer, the insured person must apply with details of policy and claims at least 45 days before the date of expiry of policy. Portability shall be allowed in the following cases : a. All Individual Health Insurance Policies issued by non-life insurance companies including family floater policies. b. Individual members, including the family members covered under any Group Health insurance policy of a non-life insurance company shall have the right to migrate from such a group policy to an individual health insurance policy or a family floater policy with the same insurer. One year thereafter, the insured person shall be accorded the right to port to another non-life insurance company. 14 IMPORTANT NOTICE 1 The Company may revise any of the terms, conditions and exceptions of this insurance including the premium payable on renewal in accordance with the guidelines/ rules framed by the Insurance Regulatory and Development Authority (IRDA) and after obtaining prior approval from the Authority. We shall notify you of such changes at least three months before the revision are to take effect. 2 The Company may also withdraw the insurance as offered hereunder after following the due process as laid down by the IRDA and after obtaining prior approval of the Authority and we shall offer to cover you under such revised/new terms, conditions, exception and premium for which we shall have obtained prior approval from the Authority. This Prospectus shall form part of your proposal form hence please sign as you have noted the contents of this prospectus. For full details, please log on to or visit our office. Signature Name Place Date Health Insurance Prospectus - Platinum 8